Fiedor v. Qwest Disability Plan

498 F.Supp.2d 1221

Pearl J. FIEDOR, Plaintiff, v. QWEST DISABILITY PLAN and Qwest Communications International, Inc., Defendants.

Civil No. 05-2065 (MJD/JJG).

United States District Court, D. Minnesota.

July 27, 2007.

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I. Chris Ritts and John C. Dunlap, Dunlap & Ritts, PA, Minneapolis, MN, Counsel for Plaintiff.

Bradley J. Lindeman, Meagher & Geer, PLLP, Minneapolis, MN, Donald W. Heyrich, Law Office of Donald W. Heyrich PLLC; and Thomas M. Affolter, Perkins Coie, Counsel for Defendants.

MEMORANDUM OF LAW & ORDER

DAVIS, District Judge.

I. INTRODUCTION

This matter is before the Court on Defendants' Motion for Summary Judgment [Docket No. 16] and Plaintiff's Motion for Summary Judgment [Docket No. 19]. The Court heard oral argument on April 25, 2007.

II. BACKGROUND

A. Factual Background

1. The Parties

Plaintiff Pearl Fiedor was employed at Defendant Qwest Communications International, Inc. ("Qwest") as a sales and service consultant from March 30, 1998 until January 14, 2005. (Administrative Record ("A.R.") Q0079.) Her job primarily involved telephone sales, which required her to sit for prolonged periods of time connected to a telephone and a computer. (Id. Q0116.) Qwest classified her position as "sedentary." (Id. Q0079.)

2. The Plan

At the times relevant to this lawsuit, Fiedor was covered by Defendant Qwest Disability Plan ("Plan"). (A.R.Q0296-361.) The Plan is a self-funded employee welfare benefit plan that provides both short-term and long-term disability benefits. Qwest is the plan sponsor and the plan administrator. (Id. Q0357.)

Under the Plan, eligible employees can obtain short-term disability benefits for up to fifty-two or seventy-eight weeks. (A.R.Q0318.) Participants must exhaust their short-term disability benefits before they are eligible for long-term disability benefits. (Id.)

In order to qualify for short-term disability benefits, a participant must first be disabled. "Disability" means

an illness or injury, supported by objective medical documentation, that prevents you from performing the normal job duties of your regular job or any other job to which you may be assigned (with or without modification).

(A.R.Q0337.)

Additionally, the participant must notify health services of her absence, seek proper care and treatment in a timely manner from an approved provider, follow a recommended treatment plan, and provide documentation supporting total disability within a reasonable period not to exceed three weeks from the first day of absence. (A.R.Q0307-08.) Specifically, a participant must

[p]rovide documentation supporting total Disability (or Disability requiring reduced hours) to Health Services within a reasonable period not to exceed three weeks from the first day of absence, and after each follow-up visit with a Provider (or as often as requested by Health Services). Documentation must be from the original dated medical record and support the claim of total Disability (or partial Disability requiring reduced hours, if appropriate). Such documentation shall include: the patient's subjective complaints or "story of illness"; the objective, measurable, or reproducible findings from physical examination and supporting laboratory or diagnostic tests; assessment or diagnostic formulation; and a plan for treatment or management of the problem. The documentation must be legible and sufficient to allow another trained medical professional to review the case, and see how the original Provider came to his determination and decisions.

(A.R.Q0307-08.)

Under the Plan, once granted, short-term disability payments will continue until "the participant is certified by Health Services as able to return to work full-time or their current scheduled hours either with or without Medical Restrictions;" fifty-two or seventy-eight weeks have expired; the Participant fails to satisfy all eligibility requirements; the Participant receive excessive disability income from other sources; or Plan coverage ends. (A.R.Q0316.)

Since April 2004, all claims for benefits and appeals have been administered by a third-party administrator, The Reed Group, working under the name "Qwest Disability Services." (Whitehurst Decl. ¶ 2.)

The Third Party Administrator shall have the right and discretion to determine for all parties, all matters of fact or interpretation relating to the administration of Plan provisions, including questions of eligibility and any other matters. The decisions rendered by the Third Party Administrator shall be conclusive and binding on all persons subject only to the right to appeal under the terms of this Plan.

(A.R.Q0358.)

If the Plan is unable to render a decision because of a claimant's failure to submit the necessary information, the claimant shall receive a notice and have 45 days following the receipt of this notice to submit the necessary information. (A.R.Q0360.) On appeal, the following rules apply:

The appeal shall be conducted by the Reviewing Party. No member of the Reviewing Party may have been involved in the initial adverse benefit determination. The Reviewing Party shall not afford deference to the initial determination, and shall take into account all comments, documents, records, and other information submitted by the Claimant relating to the claim, without regard to whether such information was submitted or considered in the initial determination.... The Reviewing Party shall have full discretion to determine all matters of fact or interpretation relating to the appeal.

(A.R.Q0360.)

3. Fiedor's Previous Medical History

In the past, Fiedor experienced a back condition that required multiple back surgeries, including multi-level lumbar fusion with placement of stabilization or Harrington rods. (A.R. Q0010-11; Q0035.) On June 30, 2001, Fiedor was in a car accident that aggravated her lower back condition, caused a neck injury with symptoms in her arms, and caused post-traumatic stress disorder with heightened depression. (A.R.Q0037.)

Effective February 6, 2002, Qwest, through its third-party administrator, approved Fiedor's Family Medical Leave Act ("FMLA") request based on her medical conditions. (A.R.Q0151-56.) The approval was for leave for "intermittent incapacity" and for planned medical appointments. (Id. Q0151.)

On April 27, 2002, an MRI revealed a minimal posterior disc bulging at the C6-7 level. (A.R.Q0033-34.)

In April 2004, Fiedor's neurologist, Dr. Steven F. Noran, M.D., stated, "[Fiedor] is not missing work simply because she cannot. They are very demanding of her time and it is difficult to get time off to do things." (A.R.Q0072.) Noran recommended that, because of her back condition, Fiedor only work overtime "at her discretion as her condition would permit." (Id. Q0073.)

On June 21, 2004, Fiedor was involved in another car accident, which further aggravated her back condition. (A.R.Q0064-65.) On July 8, 2004, she told Noran that her symptoms had increased and it was "making it very difficult to stay at work." (Id)

4. Fiedor's Short-Term Disability Benefits Application

On July 19, 2004, Fiedor called Defendants by telephone and stated that she had been in an automobile accident approximately three weeks earlier and had injured her neck. (A.R.Q0081.) She requested short-term disability benefits. (Id.) She stated that her intended first day of absence ("FDA") was July 24, 2004. (Id.) Defendants provided the necessary forms to her and told her that she needed to provide medical information to support her disability claim no later than August 17, 2004.(Id.)

On July 22, 2004, Fiedor told Defendants that she was changing her FDA to August 17, 2004. (A.R.Q0082.)

On August 5, 2004, Fiedor visited Noran. (A.R.Q0057-58.)

On September 7, 2004, Defendants received medical records from the Noran Clinic dated July 8, 2004; July 20, 2004; and August 5, 2004. (A.R.Q0083.) The July 8 report stated the following under the title "OBJECTIVE DATA:"

The patient appears tired, depressed, and near tears, at times. There is tenderness over the paraspinous cervical muscle, right greater than left. Spasm is noted on the right side. She has positive Spurling's sign on the right side. Negative Tinel's and Phalen's sign on the right. No autolyzing weakness is noted in the arms or legs. She has a flattened lordotic curvature and spasm in the low back. She has a scar from her old surgery. There is acute tenderness over the sacroiliac joint on the right side and acute tenderness of the trochanteric bursa. There is positive intertrochanteric band stretch test. Straight leg raising causes low back pain only. Motor, reflex, sensory, and cerebellar exams are otherwise unchanged. There is no sign of myelopathy, at this time. (A.R.Q0064-65.) On that date, Fiedor told Noran that her symptoms had increased and it was "making it very difficult to stay at work." (Id. Q0064.) Fiedor reported that she was not doing well before the accident, but was doing worse since the accident and could not sit for prolonged periods because of hip and low back pain. (Id.) Noran noted, "I have offered to take her off work and get her into physical therapy, but, because of the company she works for, which is Quest [sic] and the type of work that she does, she is afraid she would not be able to take time off work or that she might jeopardize her employment." (Id. Q0065.)

The MRI scan taken on July 20, 2004, showed minimal posterior disc bulging at the C6-7 level, which was the same observation as during her previous MRI on April 27, 2002. (A.R.Q0102-03.)

Noran's August 5, 2004, report noted the following under the heading of OBJECTIVE DATA:

Ms. Fiedor's appearance remains essentially the same as last time. She has positive Tinel signs over the right median nerve now. Her EMG really does not show an appreciable change from her last visit. I have been able to personally review her cervical MRI scan. It does not show any change from her...